estrategias asistenciales para evitar el colapso en los...

Estrategias asistenciales para evitar el colapso en los Servicios de

Urgencias Hospitalarios (SUH)

En primer lugar y, a pesar o a propósito del título, es necesario hacer una

reflexión antes de continuar: ¿Es adecuado hablar de colapso de los SUH?.

Cuando leo esta expresión tan utilizada en los medios de comunicación me

preocupa lo que debe pensar un ciudadano que está en su casa tranquilamente

sobre qué ocurriría si en ese momento tuviera una urgencia que requiriera una

atención inmediata. Todos sabemos lo que ocurriría: llamaría al teléfono de

emergencias y con toda celeridad sería atendido en el servicio de urgencias más

adecuado según el motivo de consulta y el nivel de triaje. ¿Eso es propio de un

sistema colapsado? No, porque los SUH nos hemos organizado para poder

atender las urgencias que no admiten demora. Por tanto, en lugar de colapsado,

sería más adecuado hablar de saturación.

Es cierto que la saturación nos obliga a priorizar y que además tiene efectos

indeseados para pacientes, familiares y para profesionales, por lo que debemos

de hacer todo lo posible para reducirla a la mínima expresión y evitar cualquier

riesgo para el paciente y mejorar las condiciones de trabajo de los profesionales.

Un sistema público, accesible y universal, con una capacidad limitada de

recursos y con una demanda no controlada, tendrá cierto grado de saturación,

por tanto, nuestro objetivo será disminuir al mínimo la saturación, dentro de

nuestras posibilidades reales, pero en nuestro máximo nivel de saturación

hemos de perseguir conseguir mantener la eficacia con el menor riesgo para el

paciente.

La saturación de los servicios de urgencias es un problema universal que afecta

a países con sistemas de salud tan dispares como USA, Canadá, Australia,

Inglaterra, Francia, Brasil, México, Nueva Zelanda o Taiwan. Las causas de esta

saturación, según el modelo conceptual de Asplin et al (AEM 2003) pueden

diferenciarse en:

Causas relacionadas con las entradas: incrementos de demanda y

variaciones de frecuentación horaria, picos de afluencia hivernales, excesivo

uso de los SUH para patologías no graves, pacientes multifrecuentadores,

déficit de resolución de otros niveles de atención (atención primaria,

derivaciones innecesarias desde consultas externas hospitalarias).

Causas relacionadas con el proceso de atención: ausencia de criterios de

selección por gravedad o retraso en el triaje, déficit estructural, retraso en la

realización o en el resultado de las pruebas de laboratorio o radiológicas,

inadecuado dimensionamiento de las plantillas, falta de profesionalización,

retraso en la toma de decisión.

Causas relacionadas con el drenaje: retraso en el ingreso hospitalario y

retraso en el traslado a domicilio o a otro centro (déficit de transporte sanitario

o falta de aceptación por parte del paciente o de su entorno).

La saturación de los SUH tiene múltiples consecuencias indeseables tanto para

los pacientes, para los profesionales y para los propios centros hospitalarios y

es un problema que debe afrontarse por parte de la administración, de las

direcciones de los centros, de los profesionales y de los ciudadanos en su

adecuada cota de responsabilidad. Vamos a analizar las posibles medidas en

función de las causa.

Sobre las entradas

Para mejorar el efecto de las entradas hemos de regular o disminuir la demanda

o aumentar la oferta. En ambos casos, la responsabilidad es de quienes

planifican la política sanitaria y la disponibilidad de recursos.

Regulación de la demanda.

Nuestro sistema nacional de salud, o los 19 que tenemos, tienen como

característica común una serie de valores entre los que destaca la accesibilidad.

En la práctica sólo hay accesibilidad no regulada a los servicios de urgencias.

Esta es una de las primeras causas de la saturación: la falta de control sobre el

flujo de pacientes. De todos modos, por lo que se refiere a los SUH, la regulación

del flujo sólo mejora la saturación debida a las urgencias de baja gravedad, que

no son la principal causa de saturación de los SUH. En cualquier caso, son las

autoridades políticas quienes tienen la responsabilidad sobre las soluciones que

pasan por:

1. Corresponsabilizar a los ciudadanos.

2. Triaje telefónico como medida previa al acceso a un SUH.

Mejorar la oferta.

Potenciar los dispositivos de AP o incrementar los dispositivos hospitalarios de

urgencias son medidas de aumento de oferta. Por lo que se refiere a la

potenciación de los SU de AP, no consiguen el objetivo de una reducción

manifiesta de las visitas a los SUH por lo que se debería de acompañar de

medidas de regulación de flujo (triaje telefónico previo al acceso a cualquier SUH

y por cualquier motivo). Aumentar los dispositivos hospitalarios de urgencias es

una medida coste efectiva muy cara dado que ocurre cuando se abren nuevos

hospitales y no tiene el impacto proporcional.

Sobre el proceso

Mejorar cada uno de los aspectos del proceso de atención urgente es una

medida con coste pero una de las más eficaces porque acaba reduciendo el

tiempo de toma de decisión. Para ello se necesita una alta implicación de: la

dirección, puesto que debe de dotar de los recursos estructurales necesarios al

SUH, adecuar las plantillas y concederles la gestión de unidades alternativas a

la hospitalización; de los responsables de los SUH, con una adecuada gestión

de los recursos, un plan de calidad y de seguridad clínica y una buena motivación

y formación de los profesionales; de los propios profesionales, que deben

hacerse responsables de tomar la decisión más adecuada en el menor tiempo

posible; y de los profesionales de otros servicios, ya sean servicios centrales o

de pruebas diagnósticas, como servicios clínicos, que deben de atender al

demanda desde el SUH con la mayor celeridad.

Por tanto, estas medidas, que dependen exclusivamente del propio centro,

deben de tomarse siempre además de actuar sobre otras causas de la

saturación.

Sobre el drenaje

Actuar sobre el drenaje interno (que depende del propio centro) o externo (que

depende de centros receptores de pacientes y del transporte sanitario) es la

medida más eficaz para paliar la saturación de los SUH, puesto que el consumo

de tiempo y de recursos propios del SUH por pacientes sobre los que ya se ha

tomado una decisión es uno de los principales motivos de saturación. Nos vamos

a fijar especialmente en la gestión de camas hospitalarias para entender qué

podemos hacer y cómo hacerlo.

Gestión de camas hospitalarias

La vía de acceso a la cama hospitalaria es doble: desde el SUH o como resultado

de un ingreso programado. Se denomina presión de urgencias al indicador que

relaciona los ingresos procedentes del SUH respecto del total de ingresos del

centro. Este índice, en los hospitales públicos no monográficos, puede oscilar

entre el 50 y el 80%. La mayoría de los pacientes que ingresan programados son

pacientes quirúrgicos, procedentes de la lista de espera quirúrgica, mientras que

los pacientes que proceden de los SUH en su gran mayoría son pacientes con

patología y tratamiento médicos, con un porcentaje mucho menor de ingreso por

otras causas (pediatría, obstetricia, procedimientos quirúrgicos, psiquiatría).

Dos de los mayores problemas que afrontan nuestro sistema nacional de salud

son precisamente la saturación de los SUH y las listas de espera quirúrgicas.

Por tanto es necesario abordarlos simultáneamente y, en ambos casos, la

eficiencia en la gestión de camas es imprescindible para conseguir la solución

simultánea a ambos problemas. En los pacientes quirúrgicos, la

ambulatorización de los procedimientos (cirugía mayor ambulatoria), la

reducción de la estancia pre-quirúrgica (ingreso el mismo día de la intervención

salvo excepciones), la gestión clínica evitando complicaciones y el uso de las

alternativas a la hospitalización convencional (AHC) son algunas de las medidas

a adoptar que evitarán ingresos innecesarios y acortarán estancias. En el caso

de los pacientes médicos, mejorar la adecuación de ingreso utilizando

adecuadamente las AHC o acortar estancias mejorando la continuidad

asistencial con otros niveles asistenciales o de nuevo utilizando las AHC, pueden

ser una de las medidas más eficaces. Si a todo ello unimos una gestión

centralizada de camas por parte de la dirección de los hospitales y, en el caso

de la gestión del ingreso urgente, una participación activa de los gestores de los

SUH, podemos mejorar simultáneamente la adecuación de ingreso y la estancia

media global, liberando camas tanto para el ingreso quirúrgico como médico,

paliando la saturación del SUH y facilitando que se mantenga la programación

quirúrgica.

ACEP TAsk ForCE rEPorT on BoArding

Emergency Department Crowding: High-Impact Solutions

APril 2008

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Emergency Department Crowding: High-Impact Solutions Continuing Medical Education Credit information

Release date: July 25, 2008Expiration date: July 24, 2011

Statement of NeedMany emergency departments in the United States are

critically overcrowded, and this hampers the delivery of high-quality medical care. The primary cause of overcrowding is boarding—the practice of holding patients in the emergency department after they have been admitted to the hospital because no inpatient beds are available. This practice often results in patients’ lying on gurneys in emergency department corridors for hours and even days, which affects not only their care and comfort but also the primary work of the emergency department staff—taking care of emergency department patients. In August 2007, the American College of Emergency Physicians established a task force to develop low-cost or no-cost solutions to boarding. The task force report, “Emergency Department Crowding: High-Impact Solutions,” was published in April 2008 to help emergency physicians stop boarding in their own hospitals and ultimately improve patient care.

From the 2007 Model of the Clinical Practice of Emergency Medicine

Appendix 2. Other components of the practice of emergency medicine

Administration

Method of ParticipationThis educational activity consists of a 14-page report, eight

post-test questions, and four evaluation questions and should take approximately 2 hours to complete. To complete this educational activity as designed, the participant should, in order, review the learner objectives, read the report, and complete and submit the online CME post-test, including the evaluation questions. Participants may submit the post-test at any time up to 3 years from the release date. No credit will be given after that date.

Thirty days after submitting the post-test, participants will be asked to answer five questions regarding how they have implemented the recommendations and whether the recommendations helped their emergency departments eliminate boarding and improve patient care.

Learner ObjectivesOn completion of this activity, you should be able to:

Define emergency department crowding.1. Discuss causes of emergency department crowding.2. Describe the consequences of crowding.3. Delineate actions that can help eliminate crowding.4.

Accreditation StatementThe American College of Emergency Physicians (ACEP) is

accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. ACEP designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Approved by ACEP for 2 hours of ACEP Category I credits.

Target AudienceThis educational activity has been developed for emergency

physicians.

ContributorsBrent Asplin, MD, MPH, FACEP, Department Head of

Emergency Medicine, Regions Hospital, St. Paul, Minnesota; Associate Professor and Vice Chair, Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota

Frederick C. Blum, MD, FACEP, West Virginia University, Morgantown, West Virginia

Robert I. Broida, MD, FACEP, Chief Operating Officer, Physicians Specialty Ltd., RRG, (Emergency Medicine Physicians, Ltd.); President, ED Quality Solutions, Inc., Akron, Ohio

W. Richard Bukata, MD, Clinical Professor, Emergency Medicine, Los Angeles County/University of Southern California Medical Center, Los Angeles; Medical Director, Emergency Department, San Gabriel Valley Medical Center, San Gabriel, California.

Michael B. Hill, MD, FACEP, President and CEO, EMPATH Consulting, Richmond, California

Stephen R. Hoffenberg, MD, FACEP, President, CarePoint Medical Group, Denver, Colorado.

Sandra M. Schneider, MD, FACEP, Board Liaison, Professor and Chair Emeritus, Department of Emergency Medicine, University of Rochester, Rochester, New York

Peter Viccellio, MD, FACEP, Chairman, Professor and Vice Chairman, Department of Emergency Medicine, State University of New York at Stonybrook, Stonybrook, New York

Shari J. Welch, MD, FACEP, Quality Improvement Consultant and Educator, Intermountain Healthcare, Utah Emergency Physicians, University of Utah, Institute for Healthcare Improvement, Salt Lake City, Utah

Publisher’s NoticeIn accordance with ACCME Standards and ACEP policy,

all persons who are in a position to control the content of this educational activity must disclose to participants the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter, including the sponsor of this educational activity, if applicable.

The contributors to “Emergency Department Crowding: High-Impact Solutions” have disclosed the following interests or relationships: Dr. Hill is President and CEO of EMPATH Consulting, an organization devoted to improving hospital operations. Dr. Asplin, Dr. Blum, Dr. Broida, Dr. Bukata, Dr. Hoffenberg, Dr. Schneider, Dr. Viccellio, and Dr. Welch have no significant financial interests or relationships to disclose.

ACEP expects that the relationships contributors disclose, if any, will not influence their contributions. ACEP also expects contributors to present information in an objective manner without endorsement or criticism of specific products or services.

ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are, nevertheless, advised that the statements and opinions expressed in this program are provided as guidelines and should not be construed as College policy unless specifically referred to as such. The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this educational activity are those of the contributors and not necessarily the opinion or recommendations of the American College of Emergency Physicians. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.

Copyright 2008, American College of Emergency Physicians. All rights reserved. Printed in the USA. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means or stored in a database or retrieval system without prior written permission of the publisher.

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ACEP BoArding TAsk ForCE MEMBErs And lEAdErshiP

Boarding Task Force Members

Peter Viccellio, MD, FACEP, Chairman

Sandra M. Schneider, MD, FACEP, Board Liaison

Brent Asplin, MD, MPH, FACEP

Frederick Blum, MD, FACEP

Robert I. Broida, MD, FACEP

W. Richard Bukata, MD

Michael B. Hill, MD, FACEP

Stephen Hoffenberg, MD, FACEP

Shari J. Welch, MD, FACEP

ACEP Leadership

Linda Lawrence, MD, FACEP, President of ACEP (2007-08)

Brian Keaton, MD, FACEP, President of ACEP (2006-07)

Dean Wilkerson, JD, MBA, CAE, Executive Director

Marilyn E. Bromley, RN, Staff Liaison

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ConTEnTs

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 High-Impact Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Additional Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 “Solutions” That Are Not Effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The Impact of Emergency Department Overcrowding on Patient Care and Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Overcrowded Emergency Departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Four Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1. Emergency Department Crowding: What Is It? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2. What Causes Crowding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 3. What Are the Consequences of Crowding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4. What Can Be Done to Reduce Crowding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Internal Emergency Department Actions and Processes That Will Improve Access and Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Hospital Actions and Processes That Will Improve Access and Flow . . . . . . . . . . . . . . . . . 12

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

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Many emergency departments in the United States are critically overcrowded and unable to re-spond to day-to-day emergencies, let alone disas-ters and acts of terrorism. Crowding is a crisis that results from the practice of “boarding,” or hold-ing, emergency patients who have been admitted to the hospital in the emergency department. Crowding occurs when no inpatient beds are avail-able in the hospital, not because of too many patients with nonurgent medical conditions seeking emer-gency care. The practice of board-ing endangers patients and results in delays in care and ambulance diversion.

When emergency patients are boarded, they lie on gurneys or sit in chairs in the emergency depart-ment, often filling every available space, including the hallways. This has a significant negative effect on patient safety, comfort, and satis-faction. It also ties up resources, rendering emergency staff un-able to care for additional patients from the wait-ing room or from an ambulance. These boarded patients wait, sometimes for days, for inpatient beds in a chaotic and unpredictable environment where children might witness a resuscitation or an elderly woman might witness a psychiatric emer-

ACEP TAsk ForCE rEPorT on BoArding

Emergency Department Crowding: High-Impact Solutions

only when all

stakeholders agree

that the problem

is systemic and

hospital-wide

can solutions be

implemented…

that will protect

everyone’s access to

emergency care.

The American College of Emergency Physicians (ACEP) in August 2007 estab-lished a task force to develop three to five low-cost or no-cost solutions to the prac-tice of “boarding,” or holding, patients admitted to the hospital in the emergency de-partment, which is the primary cause of overcrowding. The task force was charged with proposing solutions to address the growing crisis that is harming the public’s access to lifesaving emergency care. For the purposes of this report, a boarded patient is defined as a patient who remains in the emergency department after the decision to admit him or her to the hospital has been made.

gency. When ambulances are diverted, critically ill patients must travel farther for care, which delays their treatment, when seconds count.

Emergency department crowding is an institu-tional problem that goes well beyond the emer-gency department. Only when all stakeholders

agree that the problem is systemic and hospital-wide can solutions be implemented that will improve pa-tient flow from triage to discharge and protect everyone’s access to emergency care.

To begin to solve the problem, boarding must at a minimum be spread throughout the hospital by moving patients out of the emer-gency department as soon as they are admitted. This will provide a decompression valve to help allevi-ate the bottleneck caused by emer-gency patients waiting for inpatient beds. In addition, the health care industry must realign its operations to meet patients’ needs. Hospital resources must be available 7 days

a week in sufficient quantity. Surgical procedures and other activities, such as radiological services and physical therapy, should be scheduled so that these services are available 7 days a week, thus eliminating the backlog of emergency patients and ensuring continuity of care.

OVERVIEW

EMErgEnCy dEPArTMEnT Crowding: high- iMPACT soluTions

6

High-Impact SolutionsThe following solutions would have significant

impact on reducing boarding and improving the flow of patients through emergency departments:

Move emergency patients who have been •admitted to the hospital out of the emergency department to inpatient areas, such as hallways, conference rooms, and solaria (see Full Capacity Protocol at www.hospitalovercrowding.com). If each hospital unit would care for a small number of additional patients, the burden of boarding would be more evenly spread across the hospital, thus freeing the emergency department to function effectively without unduly stressing the inpatient units.Coordinate the discharge of hospital patients •before noon. Research shows that timely discharge of patients can significantly improve the flow of patients through the emergency department by making more inpatient beds available to emergency patients. However, the discharge process has become more complex, and discharging patients by noon will require leadership and a change in culture and process that must involve physicians, nurses, and staff from ambulances, nursing homes, social work, care management, pharmacy, radiology, lab, and housekeeping.Coordinate the scheduling of elective patients •and surgical patients. Studies show that the uneven influx of elective surgical patients (heaviest early in the week) is a prime contributor to hospitals exceeding their capacity.

Additional SolutionsImproving the flow of patients through

emergency departments can save time but often adds significant costs. Methods of improving flow, such as using scribes, adding nurses and support personnel, improving turnaround time for lab and X-ray (including the use of point-of-care testing), establishing electronic records, installing registration kiosks, and allowing nurses to order tests at triage (advance triage) can decrease triage to discharge time. However, the costs to implement these procedures often exceed the amount of savings they generate.

The following are additional solutions that would improve the flow of emergency patients, along with the pros and cons of each:

Bedside Registration. • Registering patients at the bedside or eliminating triage altogether (by placing patients directly in beds) can decrease wait times from triage to emergency bed and provide a small savings in time, depending on the time currently devoted to this process. However, more personnel typically are required, and

eliminating triage is possible only if empty beds exist.Fast Track Units. • Triaging patients with nonurgent medical conditions to a separate area of the emergency department for care, a practice known as “fast-tracking,” often requires more personnel but also gives staff the ability to quickly handle low-acuity patients. However, further partitioning the emergency department into separate units might not be helpful and also will create silos and obstacles to patient flow.Observation Units. • Hospitals that have added observation areas have reduced crowding, but not without significant construction and personnel costs.Physician Triage. • Involving a physician in the triage process is a costly way to discharge low-acuity patients quickly, which depending on the number of low-acuity patients might be helpful. However, referring patients away from the emergency department will require adequate options for such referrals.Cancelling elective surgeries. • This practice can greatly reduce the demand for inpatient beds, but the lost revenue is not usually offset by the care of additional emergency patients.

“Solutions” That Are Not Effective Some hospitals have expanded their emergency

departments as a way to increase their capacity to care for patients. However, this does not solve overcrowding. With less pressure on the system, the hospital might simply expand into the additional space, increasing rather than decreasing the number of admitted patients who are boarded. A more effective solution would be to add an observation area.

In addition, specified areas for discharged patients on inpatient floors tend not to be used by the inpatient nurses except when the full capacity protocol places stress on their parts of the system.

Some hospitals employ hospitalists to coordinate patient care. Using hospital-based physicians, such as hospitalists and intensivists, has been shown to decrease hospital lengths of stay but not emergency department waiting times. Ambulance diversion is used by many emergency departments, but it is increasingly evident that, in most circumstances, it simply doesn’t work. Also, a growing amount of research substantiates the harm to patients whose care is delayed because of being diverted to hospitals farther away. The research suggests the practice is both unsafe and ineffective and should be abandoned as an option for addressing the problems of hospital crowding. Some systems that have eliminated diversion as an option have not seen a worsening of crowding.


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The news media have given great attention to the crowding “crisis” in emergency departments, as if this were a recent development. However, as far back as 1987, after sustained and unsolvable problems with crowding, the first statewide conference on crowding was held in New York City, involving the New York chapter of ACEP, Emergency Medical Services, the New York State Department of Health, and legislators. At that time, the issue was clearly delineated, but no clear solutions were forthcoming. Since then, hospital and emergency department overcrowding have had cyclical media attention, albeit with very little done to fix the problem.

How did emergency departments get so overcrowded?

Hospitals in the 1960s were, in large part, places for elective admissions of patients (or scheduled surgeries), with only a small percentage of patients being unscheduled or “emergent” (seeking care for medical emergencies). Hospitals also typically had substantial capacity to allow for system-wide inefficiencies. During this time, hospitals operated primarily as 9 to 5, Monday through Friday businesses with skeleton crews on evenings, nights, and weekends.

Fast-forward to 2008, where dramatic changes have occurred in the health care system. The number of emergency visits has climbed dramatically, and most emergency visits and hospital admissions are unscheduled. The patient population also is much sicker. At the same time, the route of entry into the hospital has shifted, with the majority of patients entering through the emergency department, and with most coming in the afternoons and evenings.

Despite this significant shift, hospitals have not adapted to the changes and continue to function as 9 to 5, Monday through Friday institutions with skeleton crews on evenings, nights, and weekends. This has resulted in a mismatch of resources versus needs, generating serious lack of capacity issues, which perhaps explains in part why higher death rates for strokes and heart attacks occur among patients admitted on weekends versus weekdays.

In addition, contrary to the conventional wisdom that emergency patient volume is highly unpredictable, the number of admissions per day now can be predicted with remarkable accuracy. However, hospitals still do not anticipate and

prepare for the next day’s volume and admission through the emergency department.

So how does the institutional structure create capacity issues by design? A classic example is the coordination of surgical procedures, which are not scheduled smoothly throughout the week, but rather are front-loaded on Mondays through Wednesdays.

Why? Often because of critical followup care demands. For example, an orthopedist knows that a patient undergoing hip replacement is critically dependent upon physical therapy in the days immediately following surgery to prevent life-threatening postoperative complications and to optimize recovery of functional capacity. So if the hospital’s physical therapy staff is small or nonexistent on weekends, the orthopedist has little choice but to schedule as much surgery as possible at the beginning of the week.

How can this problem be solved? Simply by expanding capacity beyond the 9 to 5 weekday schedule. As proof in point, when an institution in Massachusetts, which had struggled with capacity issues for years, changed to a smooth surgical schedule, their capacity issues disappeared.

Overcrowded Emergency Departments As part of the problem-solving process, it is

important to distinguish what crowding means in the emergency department versus the inpatient units of most hospitals. Inpatient units, when their normal patient beds are full, are considered “full” and thus not “capable” of taking more patients. Emergency departments are considered “full” when all their rooms are full, all their hallway stretchers are full, and all their chairs are full. Thus, there is a striking contrast between the emergency department and the inpatient units in their respective views of what constitutes “at capacity,” or being crowded.

Four QuestionsThe answers to four questions will provide insight

into the causes of and solutions to crowding. (1) Emergency Department Crowding: What Is

It? Various studies have developed definitions of crowding, but in its simplest form, it exists when there is no space left to meet the timely needs of the next patient who needs emergency care. If the care of urgent problems is delayed due to congestion,

The Impact of Emergency Department Overcrowding on Patient Care and Survival


8

then crowding exists.(2) What Causes Crowding? Recently, there has

been greater understanding of why boarding—the practice of holding admitted patients in the emergency department when there is no “proper” space for them in the institution—is the primary cause of overcrowding. Over the years, the reasons for crowding have included seasonal illnesses and visits by the poor and uninsured who have nowhere else to turn except the “safety net” provided by emergency departments. This latter trend has resulted from the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospital emergency departments to medically screen and stabilize all patients with medical emergencies, regardless of their ability to pay.

Much of the research about “unnecessary” visits was published in the 1980s and early 1990s and consisted of retrospective reviews of the final diagnoses of emergency patients, not their symptoms. Once the diagnoses were known, researchers concluded the visits did not constitute emergencies and were unnecessary. Based on this research, there was a growing sense that many emergency patients were seeking emergency care frivolously, giving rise to attempts to restrict visits, increase co-pays, institute phone screening prior to visit, and other interventions.

However, many people experience the symptoms of a medical emergency, but after a medical examination and diagnostic testing, it is determined they do not have medical emergencies. These visits should not be classified as unnecessary. Just as a “spot” on the lung might mean nothing or indicate a malignancy, a child with a fever might have a simple cold or severe sepsis or meningitis. A “simple sore throat” might be viral or represent impending airway obstruction from epiglottitis; what the patient experiences is the same: a sore throat.

During the 1990s, ACEP began to advocate for a national “prudent layperson standard,” which bases health care coverage on a patient’s symptoms, not his or her final diagnosis, since the general public should not be expected to self-diagnose their medical conditions. In a study by Franaszek,1 patients were asked at triage to assess whether their problem was critical, urgent, or routine. Of the patients whom the physician determined to be critical, 25% believed their problem was routine. Other studies have shown that barriers to care (phone screening, increasing co-pays, etc.) affect

those with real emergencies as much as those with minor problems.

The critical question to ask regarding “unnecessary” visits is: “Do nonemergent patients interfere with the care of urgent patients?” Recent studies closely examined the effect of nonemergent patients on the care of critically ill patients and concluded the impact essentially is nonexistent.

How do EMTALA, the poor, and the safety net role of emergency departments contribute to crowding? EMTALA requires patients to be medically evaluated, and if there is a medical emergency, to provide whatever treatment is required to stabilize them, regardless of their ability to pay. Thus EMTALA concerns, as well as issues related to the poor and the uninsured, are issues of finance, not crowding. No evidence supports or refutes the effects of these issues on crowding, other than the well-documented increase in serious medical problems in patients who have no health insurance.

Do seasonal variations contribute to crowding? More patients do seek emergency care during a flu epidemic. However, this is a problem that is

layered on top of a chronic, day-to-day, month-to-month issue with crowding. Crowding is a year-round phenomenon, not a transient problem caused by seasonal variation.

A number of recent studies show a direct and strong correlation between the number of admitted patients being boarded in the emergency department and crowding, making it clear beyond

question that this is the number one cause of overcrowding. In short, it is not the emergency department that is causing the crowding. It is the hospital that is unable to accommodate more inpatients.

(3) What Are the Consequences of Crowding? A wealth of research demonstrates the severe

consequences of emergency department crowding on patients and physicians. Among the findings are the following:

Sick people wait too long to receive emergency •care. The Centers for Disease Control and Prevention (CDC) found, for patients judged by the triage nurse to be critical, more than 10% waited more than 1 hour to see a physician in the emergency department.2 This is a critical problem, because many illnesses are time dependent, and early intervention gives rise to better outcomes. Late diagnoses might be too late, with permanent consequences of disability

The clearest

cause of crowding

is the boarding of

admitted patients.


9

or death.3 Waiting times can be reduced by reducing access block.4

Another study examined the complication rate •among patients with acute coronary syndrome (ACS) and found a significant increase in serious complications (approximately 6% versus 3% incidence of death, cardiac arrest, heart failure, late MI, VTach or VFib, SVT, bradycardia, stroke, or hypotension) in patients seeking emergency care during times of crowding.5

Boarding increases the total length of stay in the •hospital, further worsening access to emergency care. Several studies document a total hospital length of stay to be a full day longer among patients boarded in the emergency department versus patients with similar illnesses promptly placed in the inpatient units.6-8

Boarding increases walkouts • . The longer people wait, the greater the likelihood they will leave prior to receiving care.9 Unfortunately, the percentage of patients with serious illness differs little between patients who left and those who waited for care. A number of these walkouts subsequently require admission.10

Overcrowding increases medical errors. • A number of articles document the increase in medical errors associated with boarding and crowding.11 Many of these are errors of omission and not commission since the emergency staff must simultaneously care for inpatients and focus on the new emergencies coming in the door.12 According to the Joint Commission, 50% of sentinel events causing serious injury or death occur in the emergency department, and approximately one third of these are related to crowding.13

Overcrowding causes deaths. • The emergency medicine community has long been aware of the dangers of crowding and delays in care. Several recent studies, looking at large databases that compare mortality rates in patients seeking emergency care during times of crowding versus times of no crowding, conclude that the rate of death is higher during times of crowding. This effect (hazard ratio for death of approximately 1.3)14-16 offers a target larger than those of other initiatives given great importance, such as the administration of antibiotics for pneumonia patients within 4 hours, which now is a performance measure by which hospitals are paid. Compliance with this initiative is estimated to reduce the number per 100 who would have died to 93. Crowding studies estimate that deaths

would be reduced from 100 to between 75 and 83. These are substantial numbers and apply to a very large population. As such, crowding appears to be a far more important issue to resolve.

Chalfin and colleagues (2007) looked at outcomes •for intensive care unit (ICU) patients subjected to a delay of more than 6 hours in transfer to an ICU, and found increased hospital length of stay (7 versus 6 days) and higher mortality rates (10.7% versus 8.4%) for these patients.17

Crowding causes ambulance diversion. • According to the CDC, approximately 50% of emergency departments experience crowding, and one third of hospitals have experienced ambulance diversion.18 Ninety percent of emergency department directors report crowding as a recurrent problem,19 and other studies have reported ambulance diversion in up to 50% of emergency departments.20 Such crowding and diversion have raised an alarm regarding the ability of the health care system to respond to catastrophe.21

Interestingly, there is scant evidence that •ambulance diversion actually works,22 although evidence exists for delayed care in the face of ambulance diversion.23 In this regard, study author Nicholl demonstrated an increased mortality rate with prolonged transport times.24

It is clear that ambulance diversion is driven •by the boarding of admitted patients and is not otherwise related to issues of staffing or space within the emergency department itself.25

Boarding of inpatients interferes with the •patient-centered care model. Many hospitals are adopting patient-centered care, which means that continuity teams care for patients during their stay. Intuitively, if patients spend a portion of their stay in the emergency department rather than on an appropriate floor, continuity is impossible.

Crowding increases medical negligence claims, •which increases health care costs for everyone. The frequency of medical liability lawsuits filed against emergency physicians is increased by a factor of five simply based on whether a patient waits more than, rather than less than, 30 minutes to be seen by a physician.


10

Most importantly, patient care is worsened by boarding. Evidence-based research demonstrates that boarding results in the following:

Delays in care •

Ambulance diversion •

Increased hospital lengths of stay •

Medical errors •

Increased patient mortality •

Financial losses to hospital and physician •

Medical negligence claims •

(4) What Can Be Done to Reduce Crowding?This section is divided into actions and processes

to solve overcrowding within and beyond the emergency department. Because crowding is a hospital problem, the greatest gains will occur by working on flows within the hospital. Improving flow through the emergency department can save small amounts of time but often adds significant cost. That being said, emergency department processes can be improved but are likely to have little effect on crowding unless matched with successful inpatient flow initiatives.

Internal Emergency Department Actions and Processes That Will Improve Access and Flow

Bedside registration • is a fundamental concept of process improvement, which seeks to streamline and increase efficiency wherever possible. Many emergency departments will triage, then register, and finally place patients in beds. Virtually all emergency patients have some waiting time during which they could be registered at the bedside, eliminating the need to wait in line to register. In adopting bedside registration, there will be a need for patients to have a “quick reg,” i.e., a basic, quick set of identifiers to register them into the hospital’s computer system. The complete registration can then be accomplished at the bedside.

Limit triage to what is crucial and bypass triage •altogether when beds are available. Many emergency departments have a triage process that applies to all patients, regardless of illness or injury severity. As a result, a line forms at triage, defeating the very purpose of triage, which is to rapidly sort out which patients need what and where. Here are some examples of ways to streamline triage: — Patients who look well, with obvious low-risk problems such as sprains and lacerations, should be sent directly to the area where they

will receive care (e.g., a fast track area) without delaying triage by obtaining vital signs and/or other information that rarely results in a change at triage. Patients who appear critically ill or injured should be sent directly to the appropriate area without delay. Thus, triage can focus more time on those patients who require more evaluation and judgment to determine the severity of their medical conditions.— If emergency beds are available, allow the patient to bypass triage and go directly to the waiting bed. When there are staff and space to see new patients, there is no value added in delaying care at triage.

Develop a fast track for treating simple fractures, •lacerations, sore throats, etc. Removing patients who can be fast tracked from the mainstream of patients helps to open space and allow resources to be directed toward sicker patients, facilitating the care of all patients. Fast track areas should be staffed consistently and appropriately.

Minimize silos within the department. • Although the value of fast tracks is well established, subdividing the emergency department can create obstacles to flow. As much as possible, maximize the use of space and increase the flow of patients by using beds for all purposes.

Expand the practice of observation medicine. •Particularly in the face of capacity limitations driven by the boarding of admitted patients, treatment of patients who could possibly avoid admission via extended observation, diagnosis, and treatment in the emergency department will help decrease capacity needs. One area of great potential for emergency physicians is the establishment of advanced chest pain protocols to improve the diagnostic process for those patients with higher risk and to discharge patients with minimal risk. Note that the practice of observation medicine or establishment of protocols to rule out ACS in the emergency department does not require that a particular space be sequestered for such a practice, although that might be ideal. Overall, the greater the capacity issue, the more the emergency department, the hospital, and the patients are served by establishing such protocols in the emergency department, by reducing the number of patients who will need hospitalization. The observation unit should be under the control of the emergency department to maximize its effectiveness.

Establish clearly defined turnaround-time •(TAT) goals in the emergency department for


11

admitted and discharged patients, and commit as a department to identifying and correcting all obstacles to the realization of these TAT goals

Carefully evaluate staffing needs. • Although many staffing models exist, the same principles apply. Old staffing patterns are driven by the question: “How few resources can I possibly get by with?” As the emergency department has evolved, sicker patients, more comprehensive workups, and expansion of observation medicine have driven a reconsideration of staffing needs. The simplest measure of staffing is whether patients’ needs can be met in a timely fashion. Such measures as door-to-ECG time, door-to-antibiotics, and door-to-pain medication can be used as a proxy for adequate staffing. The temporal distribution of staff should match the flow of patients in the emergency department. As a rough rule, in order to provide reasonably timely care, no nurse should be managing more than four patients simultaneously. For the sicker patients, a nurse should care for no more than two patients. Also, consider the types and distribution of staff. Emergency departments tend to be top-heavy with physicians and nurses, with inadequate support staff. Any work that can be done by someone other than a physician or nurse should be shifted to support staff.

Use scribes for documentation. • The average emergency physician spends no less than 90 to 120 minutes in 8 hours on documentation. The use of scribes can reduce or eliminate this task for physicians, allowing them to see more patients in a timely manner. With appropriate attention to proper documentation, a scribe program will easily pay for itself. The use of scribes for nurses is unstudied, although few would question the burden of documentation borne by the nursing staff.

Decrease TAT associated with ancillary services. • Effective service for patients means rapid TAT for lab and radiology tests. Consider that, for an emergency department that sees 200 patients per day, decreasing the mean emergency department length of stay by 7.2 minutes per patient equates to having an extra bed. Small improvements in high-volume services can have a significant impact on emergency department capacity.

Close the waiting room. • Do not send patients to the waiting room after triage, even if there is no bed for the patient in the clinical space. Bring all patients waiting to be seen into the emergency department. These patients can be watched and reprioritized and will get into beds more quickly

for examination. Only patients who must remain in bed should “own” their beds during their stay.

Use protocols and order sets • for uniformity and to ensure all needed tests and interventions occur at the earliest possible point in the patient’s stay.

Consider use of an electronic medical record •(EMR). Carefully consider the value added from an EMR versus the additional staff time required to enter information. If paper records are used in the emergency department, a local scanning solution can serve as the EMR so that charts from prior visits are available. Although emphasis is placed on the benefits of having an EMR, substantial time is diverted from the patient’s bedside to the computer. Consider expanded use of scribes to ensure that physicians and nurses are functioning effectively.

Define response times for both initiation and •completion of consultations. Measure these times as an institutional policy and identify mechanisms to decrease TAT for physicians on call.

Implement triage protocols. • Initiation of protocols at triage has been shown to facilitate more timely post-triage care. However, use of protocols must be done in such a way as not to usurp the primary purpose of triage: To identify those in greatest need of timely treatment.

Assign a physician to triage. • In departments with overwhelming capacity issues, placing a physician at triage can streamline the discharge of minor patients and help initiate care for sicker patients. In general, this requires an additional physician to staff the emergency department, and consideration of the cost involved should be factored into the decision to institute this practice. As previously noted, the primary triage function should not be usurped.

Monitor individual practitioners in the •emergency department with regard to overall TAT, numbers and types of tests ordered, and percentage of patients admitted. Such data can be used to identify physician practices that need closer monitoring and/or improvement.

Deferred care of nonurgent patients. • Although practiced in some areas, there are few data to support the safety of deferring nonurgent patients to other facilities. Physicians report that, in order to determine that a patient is nonurgent, they have to do enough of an evaluation to make a diagnosis. Once the diagnosis is made, then what’s the point of deferral/referral? Note also


12

the research (cited previously) that nonurgent patients are NOT creating delays for urgent patients needing to be seen. This process of deferral of care should not be considered without first ensuring certain followup for the patient.

Expand the size of the emergency department. • Having appropriate space and staff to match the volume of emergency patients is critical to proper functioning of the emergency department. With the rapid growth of emergency patient volume, physical expansion might be necessary. Note that space increases either by increasing the physical space or by decreasing average TAT. Process improvement is substantially cheaper and probably more effective in the long run than space expansion. If the need for space is driven by boarding of admitted patients, increasing the space is likely to simply increase the amount of boarding, and thus be self-defeating.

Ambulance diversion. • Although ambulance diversion does not work to ease crowding and might result in worsening of care, the act of “going on diversion” is an effective way to notify the hospital, staff members, and the community of the crisis conditions.

Provide additional staff during times of increased •volume. This may be accomplished by using on-call physicians and nurses or by scheduling shorter shifts with the expectation that staff can be asked to come in 1 to 2 hours early or stay 1 to 2 hours late, as capacity demands. The trigger in such a system should clearly be defined by objective criteria rather than left to interpretation.

Have a clear understanding of the financial •power of the emergency department and its impact on the overall fiscal health of the institution. All stakeholders should have a clear understanding of the benefits of a well-run emergency department and the institutional damage from a poorly functioning emergency department.

Hospital Actions and Processes That Will Improve Access and Flow

Create institutional awareness of the dangers •associated with emergency department crowding due to boarding of emergency patients. Solutions can be found when there is a hospital-wide cultural awareness that crowding is a problem to be shared and solved through the efforts of the entire institution.

Match resources to needs. • Staffing should match the needs of patients. Often the evenings

represent the time of greatest activity for both discharging and admitting hospital patients, which might not be matched by nursing staff, housekeeping, or other needed services. Also, weekends tend to be understaffed when matched against patient needs.

Move toward a 24/7 operational culture. • Weekends are dangerous at hospitals, so again, match resources to patient needs. Examine patient discharges on weekends, which tend to be lower due to covering physicians who do not know the patient, and the lack of other resources on weekends (e.g., stress testing). Implement processes to improve care and facilitate discharges on weekends. Expand services and staff where needed.

Coordinate the scheduling of elective patients •and surgical cases. Studies demonstrate that the uneven influx of elective surgical patients (primarily earlier in the week) is a prime contributor to exceeding capacity in the emergency department.

Address delays in moving emergency patients •admitted to the hospital caused by waiting for nursing reports. It is paramount for communication to occur when nursing shifts change and different staff take over patient care. However, “lock-outs” in terms of when a patient report can be provided or a patient admitted to the inpatient unit must be eliminated.

Examine the discharge process and measure all •reasons for delays in discharge of the patient. Do not assume the cause is known without actually measuring it. The discharge process has become dramatically more complex. The roles and timely functions of physicians, nurses, and staff from ambulances, nursing homes, social service, care management, pharmacy, radiology, lab, other ancillary services, and housekeeping all affect the discharge process and should be examined. Identify the parts of the discharge process that can be initiated early on in anticipation of discharge. The institution must be committed to taking actions on the findings and improving the timeliness of the discharge process. Specifically, the institution must successfully maximize timely discharge to improve bed availability for those in need. One practice, reported as an Institute for Healthcare Improvement initiative, is the use of a discharge whiteboard. A small whiteboard at the head of each patient bed outlines what has to take place before the patient is discharged (e.g., physical therapy consultation, dietary consultation, etc.) This practice informs the


13

family, the patients, and the staff of what needs to happen, and they become the drivers for each process.

Have all inpatient services managed by •hospitalists, and have all ICUs managed by intensivists. This results in both care and shorter lengths of stay.

Use discharge lounges for patients awaiting •discharge. Consider moving the entire inpatient discharge process to a discharge area so that beds can be made available for patients who need admission.

Relocate admitted patients boarding in the •emergency department because of lack of available beds on the inpatient units to hallways, conference rooms, or solaria (e.g., full capacity protocol, www.hospitalovercrowding.com) within those inpatient units. With each unit taking a small number of patients, the emergency department can continue to function to care for emergencies, without unduly stressing the inpatient units.

Hire a “bed czar.” • This person should command all hospital bed use and be responsible for the appropriate and timely matching of bed resources to patient needs. Ideally, the bed czar is independent of hospital departments and reports to senior administration.

Consider an express admission unit. • For emergency patients admitted to the hospital, consider having a place away from patient care areas in the emergency department to do the paperwork for processing admissions, which can take time. This can be coupled with an express admit team from the emergency department dedicated to getting patients upstairs.

Consider the use of a generic admission order •set initiated by the emergency physician. This order set would be limited to basic orders, such as activity, diet, allergies, DNR [do not resuscitate] status, and perhaps a single order for pain medication. It is not effective for the emergency physician to be responsible for writing comprehensive treatment orders for admitted patients.

Establish hospital-wide protocols for addressing •capacity issues in the emergency department and implement an alert system when the hospital is over capacity. Identify circumstances for alerts and actions to be taken. Measure the success, and use the measurements to modify and improve the alert system.

Cancel elective admissions when hospital •capacity is at maximum.

REFERENCES1. Franaszek JB. Moonlighting. J Emerg Med.

1983;1(2):161-163. 2. QuickStats: Percentage of emergency department visits

with waiting time for a physician of > 1 hour, by race/ethnicity and triage level – United States, 2003-2004. MMWR. 2006;55(16);463.

3. Pines JM, Hollander JE, Localio AR, et al. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. 2006;13(8):873-878.

4. Dunn R. Reduced access block causes shorter emergency department waiting times: An historical control observational study. Emerg Med (Fremantle). 2003;15(3),232–238.

5. Pines JM, Hollander JE. Association between cardiovascular complications and ED crowding. American College of Emergency Physicians 2007 Scientific Assembly; October 8-11, 2007; Seattle, WA.

6. Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994;12(3):265-266.

7. Richardson DB. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust. 2002;177(9):492-495.

8. Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179(10):524-526.

9. Weiss SJ, Ernst AA, Nick TG. Relationship between the National ED overcrowding scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med. 2005;23:288-294.

10. Richardson DB, Bryant M. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004;11(5):462.

11. Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448-455.

12. Cowan RM, Trzeciak S. Clinical review: emergency department overcrowding and the potential impact on the critically ill. Crit Care. 2005;9(3):291-295.

13. Joint Commission. Sentinel Event Alert, June 17, 2002; http://www.jointcommission.org/sentinelevents/statistics. Accessed 4 June 2007.

14. Lie SW, et al. Frequency of adverse events and errors among patients boarding in the emergency department. Acad Emerg Med. 2005;12(5)_suppl_1:49-50.

15. Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-212.

16. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216.

17. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477-1483.

18. Burt CW, McCaig LF. Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003–04. Advance data from vital and health statistics; no. 376. Hyattsville, MD: National Center for Health Statistics. 2006.


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19. Olshaker JS, Rathlev NK. Emergency department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the emergency department. J Emerg Med. 2006;30(3):351-356.

20. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47(4):317-326.

21. Minority staff special investigations division, committee on government reform. US House of Representatives. National preparedness: ambulance diversions impede access to emergency rooms. www.house.gov/reform/min, Oct 16, 2001.

22. Pham JC, Patel R, Millin MG, et al. The effects of ambulance diversion: a comprehensive review. Acad Emerg Med. 2006;13(11):1220-1227.

23. Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ. 2003;168(3):277-83.

24. Nicholl J, West J, Goodacre S, et al. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24(9):665-668.

25. Schull MJ, Lazier K, Vermeulen M, et al. Emergency department contributors to ambulance diversion: a quantitative analysis. Ann Emerg Med. 2003;41(4):467-476.

H E A L T H P O L I C Y / C O N C E P T S

Brent R. Asplin, MD, MPHDavid J. Magid, MD, MPHKarin V. Rhodes, MDLeif I. Solberg, MD Nicole Lurie, MD, MSPHCarlos A. Camargo, Jr., MD,

DrPH

From the Department of Emer-gency Medicine, Regions Hospi-tal and HealthPartners ResearchFoundation, and the Departmentof Emergency Medicine,University of Minnesota MedicalSchool, St. Paul and Minne-apolis, MN (Asplin); the ClinicalResearch Unit, ColoradoPermanente Medical Group, andthe Department of PreventiveMedicine and Biometrics andDivision of Emergency Medicine,University of Colorado HealthSciences Center, Denver, CO(Magid); the Section ofEmergency Medicine, Universityof Chicago Hospitals, Chicago,IL (Rhodes); the HealthPartnersResearch Foundation, Minne-apolis, MN (Solberg); RAND,Arlington, VA (Lurie); theDepartment of Emergency Medi-cine, Massachusetts GeneralHospital, and the ChanningLaboratory, Department ofMedicine, Brigham and Women’sHospital, Harvard MedicalSchool, Boston, MA (Camargo).

Copyright © 2003 by the AmericanCollege of Emergency Physicians.

0196-0644/2003/$30.00 + 0doi:10.1067/mem.2003.302

A Conceptual Model of Emergency Department

Crowding

A U G U S T 2 0 0 3 4 2 : 2 A N N A L S O F E M E R G E N C Y M E D I C I N E 1 7 3

See related article, p. 167, and editorial, p. 181.

Emergency department (ED) crowding has become a major barrier to receiving timelyemergency care in the United States. Despite widespread recognition of the problem,the research and policy agendas needed to understand and address ED crowdingare just beginning to unfold. We present a conceptual model of ED crowding to helpresearchers, administrators, and policymakers understand its causes and developpotential solutions. The conceptual model partitions ED crowding into 3 interdepend-ent components: input, throughput, and output. These components exist within anacute care system that is characterized by the delivery of unscheduled care. Thegoal of the conceptual model is to provide a practical framework on which anorganized research, policy, and operations management agenda can be based toalleviate ED crowding.

[Ann Emerg Med. 2003;42:173-180.]

C O N C E P T U A L M O D E L O F E M E R G E N C Y D E P A R T M E N TC R O W D I N G

Asplin et al

I N T R O D U C T I O N

Emergency department (ED) crowding has become amajor barrier to receiving timely emergency care in theUnited States. Patients who present to EDs often facelong waiting times to be treated and, for those whorequire admission, even longer waits for an inpatienthospital bed. Because ED crowding is a reflection oflarger supply and demand mismatches in the healthcare system, the problem cannot be solved by examina-tion of the ED in isolation. To find solutions, we mustexamine ED crowding in the context of the entire deliv-ery system by using reliable methods to understand,measure, and monitor system capacity.

We present a conceptual model of ED crowding to helpadministrators, researchers, and policymakers under-stand its causes and develop potential solutions. The con-ceptual model partitions ED crowding into 3 interdepen-dent components: input, throughput, and output.Although factors that originate in many parts of the healthcare system contribute to ED crowding, the model focuseson this problem from the perspective of the ED. We do notintend to describe all the potential causes of this complexissue. Rather, our goal is to provide a framework that willfacilitate a systematic understanding of the problem.After discussing a definition of ED crowding and the over-all acute care system, we present the model’s componentsand describe how it could guide research and operationaland policy solutions for ED crowding.

The lack of consensus definitions of ED crowdinghas been a challenge for researchers, clinicians, admin-istrators, and policymakers.1,2 In 2002, the AmericanCollege of Emergency Physicians assembled theCrowding Resources Task Force to develop a guide tohelp American College of Emergency Physicians chap-ters respond to the problem. The task force developedthe following definition of ED crowding, which we haveadopted for this article.

Emergency department crowding: A situation in which

the identified need for emergency services outstrips

available resources in the ED. This situation occurs in

hospital EDs when there are more patients than staffed

ED treatment beds and wait times exceed a reasonable

period. Crowding typically involves patients being

1 7 4 A N N A L S O F E M E R G E N C Y M E D I C I N E 4 2 : 2 A U G U S T 2 0 0 3

monitored in nontreatment areas (eg, hallways) and

awaiting ED treatment beds or inpatient beds.

Crowding may also involve an inability to appropriately

triage patients, with large numbers of patients in the ED

waiting area of any triage assessment category.3

Other authors have offered potential definitions ofED crowding and described factors that are most likelyto contribute to the problem. Schull et al2 used anexpert panel to identify factors that were deemed keydeterminants of ED crowding. They developed a con-ceptual model of ED crowding that grouped potentialcauses of crowding into 4 areas: community, patient,ED, and hospital determinants. This group identifiedambulance diversion as the most useful operational def-inition and proxy measure of ED crowding; however,because ambulance diversion is not an option for manyhospitals, and because EDs have widely variable thresh-olds for diverting ambulances, we decided that this def-inition is not generalizable to ED crowding in the UnitedStates. Schull et al also excluded factors such as theavailability of primary care in the community as animportant determinant of ED crowding. However, theirstudy was based on the Canadian health care system,where universal access to primary care is the norm. Ourgoal is not to prioritize potential causes of ED crowdingbut to provide a general conceptual framework that canbe used to study the causes and consequences of EDcrowding, as well as potential solutions.

T H E A C U T E C A R E S Y S T E M

The input-throughput-output conceptual model appliesoperations management concepts to patient flowamong health care sites that we refer to as the acute caresystem. We broadly define the acute care system toinclude any delivery system component that providesunscheduled care (Figure 1). This definition is a practi-cal way of identifying the components of the health caresystem that contribute to, or are affected by, ED crowd-ing. One important feature of the acute care system is itsinteraction with the delivery of chronic and preventivecare. The chronic care system and the acute care systemrepresent 2 sides of the same coin. They are both essen-tial components of the overall health care system, and


Asplin et al

action of these factors has a strong influence on thelocation and timing of health care use. Although ourmodel does not attempt to address patient-level factorsthat contribute to decisions to seek ED care, it doesdescribe interactions among components of the healthcare system and community that affect ED use.

In addition to the factors described in Andersen andLaake’s model,4 an understanding of ED input mustinclude the recognition that there are at least 3 generalcategories of care delivered in the ED: (1) emergencycare; (2) unscheduled urgent care; and (3) safety netcare (Figure 2). The input component of our modelhighlights these categories.

Emergency Care in the ED

The ED’s most visible and indispensable role in thecommunity is the treatment of seriously ill and injuredpatients.5 Recent evidence indicates that the propor-tion of seriously ill and injured patients may be increas-ing. In an article based on data from California, Lambeet al6 reported a 59% increase in the proportion of EDcases classified as critical care visits during the 1990s.This trend may be a partial explanation for the recentincrease in ED crowding in many parts of the country.7,8

The ED frequently serves as a referral site for otherproviders when they determine that patient stabiliza-tion and hospital admission are required. These patientsmay be referred from urgent care centers, skilled nurs-ing facilities, home health care providers, hospitals,ambulatory clinics, and other sites. Although ambula-tory clinics can admit patients with straightforwardproblems directly to the hospital, they often referpatients with complex problems to the ED for stabiliza-tion, triage, and an initial diagnostic evaluation beforeadmission. The concentration of diagnostic and thera-peutic technologies available to the ED may contributeto these referral patterns for ambulatory patients.

Unscheduled Urgent Care in the ED

The ED provides a significant amount of unscheduledurgent care, often because there is inadequate capacityfor this care in other parts of the acute care system.Many times, patients are sent to the ED because theirclinic cannot quickly treat them for an acute problem

they have many characteristics in common; however,they also have important functional distinctions thatare not based on the site of care or on patient character-istics. For example, ambulatory care clinics routinelydeliver scheduled services of all kinds, while simultane-ously providing unscheduled appointments. Likewise,patients with chronic conditions often require care inEDs for acute exacerbations of those conditions, espe-cially when their overall care is poorly organized. Thedistinction between acute and chronic care delivery istherefore a function of the urgency of the demand for careand the health system’s response. This functional distinc-tion is noteworthy because the organizational and supplycharacteristics for chronic care delivery are differentfrom those required to provide unscheduled care.

I N P U T C O M P O N E N T

The input component of ED crowding in our concep-tual model includes any condition, event, or systemcharacteristic that contributes to the demand for EDservices. This portion of the conceptual model hasproperties that are similar to existing models of healthcare use. For example, Andersen and Laake’s4 Be-havioral Model of Healthcare Utilization describes 3factors that affect use: patient need for health care ser-vices, predisposing factors that affect an individual’slikelihood of seeking care, and enabling factors thataffect an individual’s ability to receive care.4 The inter-


Figure 1.The acute care system includes the components of the healthcare system that contribute to, or are affected by, ED crowd-ing. The common link among these services is that they aredelivered as unscheduled care.

The Acute Care System• Unscheduled ambulatory care (physicians’ offices and ambulatory

care clinics)• Urgent care services• ED care• Hospital and physician services required to care for ED patients

(eg, on-call services)• Inpatient services for patients admitted from the ED• Out-of-hospital care (emergency medical services)


Asplin et al

(or an acute exacerbation of a chronic problem) orbecause other sources of after-hours care are unavail-able.9 Alternatively, patients may schedule an appoint-ment for an acute condition but come to the ED becausetheir symptoms worsen before they can be treated.Although some ambulatory care systems have had suc-cess providing same-day appointments with a schedul-ing system called advanced access,10,11 the delay for anacute appointment is often longer than patients are will-ing or able to wait. The convenience of same-day carealso influences patient decisions to seek ED care. Even ifpatients must wait to be treated in the ED, the availabil-ity of after-hours care may create fewer conflicts withemployment, educational, and family responsibilities.12

Safety Net Care in the ED

The relationship between the ED and vulnerable popula-tions highlights the “safety net” role that EDs play in the


community.13 Although the ED shares this role withother safety net providers and clinics in most communi-ties, it often is the only open door for patient populationsthat experience substantial barriers to accessingunscheduled care. Disproportionate numbers of Medi-caid beneficiaries and uninsured individuals frequentlyrely on the ED as their usual source of care, often becausecost or access barriers interfere with receiving care else-where.14,15 The ED is not only a safety net for the com-munity but also serves an important safety net functionfor the rest of the health care system.16,17 When othermedical care options in the system are exhausted, the EDis sometimes the only alternative for acute care. Recentreports from the Institute of Medicine and the GeneralAccounting Office indicate that ED crowding is moresevere in communities with higher numbers of unin-sured residents.18,19 These findings reinforce the impor-tant safety net role that EDs play in the community.

Figure 2.The input-throughput-output conceptual model of ED crowding.

Emergency care

• Seriously ill and injuredpatients from the community• Referral of patients withemergency conditions

Unscheduled urgent care

• Lack of capacity forunscheduled care in theambulatory care system• Desire for immediate care(eg, convenience, conflictswith job, family duties)

Safety net care• Vulnerable populations(eg, Medicaid beneficiaries,the uninsured)• Access barriers (eg,financial, transportation,insurance, lack of usualsource of care)

Input

Demand forED care

Patient arrives at ED

Triage and roomplacement

Diagnostic evaluationand ED treatment

ED boarding of inpatients

Patientdisposition

Leaves withouttreatmentcomplete

Ambulancediversion

Throughput

Ambulatorycare

system

Lack of access to follow-up care

Transfer to otherfacility (eg, skillednursing, referral

hospital)

Lack of availablestaffed inpatient beds

Admit tohospital

Output

ACUTE CARE SYSTEM


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inability to move admitted patients from the ED to aninpatient bed.8,19,22-25 This problem forces the ED toboard admitted patients until inpatient beds are avail-able, effectively reducing the ED’s capacity to care fornew patients. Boarding of inpatients in the ED has alsobeen cited as the most important determinant of ambu-lance diversion.26 Ongoing care for hospital inpatientsthat remain in the ED consumes nursing and physicianresources and may delay evaluation of new patients.The causes and consequences of ED boarding of inpa-tients may be the most important areas for immediateresearch and operational strategies to alleviate EDcrowding.7

Many factors contribute to inpatient boarding in theED. Examples include a lack of physical inpatient beds;a lack of inpatient bed availability because of inade-quate or inflexible nurse to patient staffing ratios, isola-tion precautions, or delays in cleaning rooms afterpatient discharge; an overreliance on intensive care ortelemetry beds; inefficient diagnostic and ancillary ser-vices on inpatient units; and delays in discharging hos-pitalized patients to post–acute care facilities. Thenursing shortage is a major limiting factor for staffedbed availability. This shortage has prompted hospitalsand policymakers to develop a variety of programs forretaining and expanding the nursing workforce. Therelative importance of the factors contributing to inade-quate inpatient bed availability likely varies by regionand hospital.

When patients are discharged from the ED, ongoingdiagnostic and therapeutic services are often required.The availability of timely follow-up appointments inthe ambulatory care system once again may createcapacity problems; however, it now creates output bot-tlenecks rather than input demands for the ED. Timespent by ED providers arranging appropriate follow-upcan undermine the efficiency of care and prolong EDlength of stay. Furthermore, when adequate arrange-ments for outpatient follow-up care cannot be made,emergency physicians are more likely to admit patientsto the hospital. For example, outpatient treatment maybe appropriate for selected patients with transientischemic attacks if they have reliable and timely follow-

T H R O U G H P U T C O M P O N E N T

The throughput component of the model identifiespatient length of stay in the ED as a potential con-tributing factor to ED crowding. This part of themodel highlights the need to look internally at EDcare processes and modify them as needed to improvetheir efficiency and effectiveness, especially thosethat have the largest effect on length of stay andresource use in the ED. There are 2 primary through-put phases in the model. The first phase includestriage, room placement, and the initial provider eval-uation. Several investigators have identified newstrategies for ED triage, a function that currentlyvaries widely across the country.20 Standardization ofED triage would facilitate a common understandingof ED patient workload. Some EDs have created inno-vative processes for rapidly placing patients in roomsand initiating the physician evaluation. Several suc-cessful EDs routinely complete triage and roomplacement within 10 minutes of patient arrival andthe initial physician evaluation within 10 minutes ofroom placement.21

The second phase of the throughput componentincludes diagnostic testing and ED treatment. In anefficient ED, this phase typically will constitute themajority of a patient’s total ED throughput time.Several factors affect throughput times during thisphase, including the cohesiveness of patient careteams, physical layout of the ED, nurse and physicianstaffing ratios, efficiency and use of diagnostic testing(eg, laboratory, radiology), accessibility of medicalinformation, quality of documentation and communi-cations systems, and availability of timely specialtyconsultation. Although this list is by no meansexhaustive, it identifies many important areas forimproving ED efficiency.

O U T P U T C O M P O N E N T

Inefficient disposition of ED patients contributes tocrowding for admitted and discharged patients.8 Themost frequently cited reason for ED crowding is the



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up care. However, if appropriate follow-up care cannotbe arranged, these patients are likely to be admitted,occupying inpatient beds that could have been used forother patients.

The ambulatory care access barriers experienced byvulnerable populations (eg, uninsured patients, Medic-aid beneficiaries, patients who do not have a usualsource of care) create dilemmas for emergency providerswho are trying to arrange appropriate follow-up care.15

This process can be time-consuming and inefficient,and for many patients, it is ultimately unsuccessful.Patients who are unable to obtain follow-up care oftenreturn to the ED if their condition does not improve ordeteriorates. Our model illustrates this problem bybringing a subset of discharged patients back to the EDfor further care. Patients who leave before completingtreatment also may return to the ED. The rate of un-scheduled return ED visits within 48 hours of dischargemay be a useful measure of inappropriate ED dischargeor inadequate access to follow-up care.8,27

A M O D E L - D R I V E N R E S E A R C H , P O L I C Y , A N DO P E R A T I O N S M A N A G E M E N T A G E N D A

The input-throughput-output conceptual model of EDcrowding may be useful for organizing a research, pol-icy, and operations management agenda to alleviate theproblem. The model illustrates the need for a systemsapproach with integrated rather than piecemeal solu-tions for ED crowding. We believe there are 4 generalareas of ED crowding that require future research.First, we must develop measures of ED crowding thatare valid, reliable, and sensitive to changes throughouttime. Second, research is needed to identify the mostimportant causes of ED crowding from each compo-nent of the model. Third, the effect of ED crowding onthe quality of patient care must be assessed. Andfinally, interventions to reduce ED crowding need to beevaluated.

The development of valid and reliable measures ofthe factors contributing to ED crowding is the first stepin developing a coherent research and policy agenda.Each component of our conceptual model contains


concepts that should be measured consistently acrosssites and throughout time. Within the input compo-nent, reproducible measures of the number and com-plexity of patients seeking ED care are needed. Wherepossible, these measures should reflect the local ambu-latory care system’s ability to deliver unscheduled care.The throughput component identifies the need to mea-sure ED capacity, workload (ie, urgency- and complexity-adjusted occupancy rates), and efficiency across sites.Key output concepts include measurement of the hos-pital’s capacity to admit new patients, the efficiency ofthe admission process (including measurement of EDboarding), and the efficiency of the hospital inpatientdischarge process.

One marker of inefficient ED care that has been linkedto adverse outcomes is patients who leave without com-pleting treatment. This marker includes patients wholeave the ED before being treated, those who leave afterstarting treatment with a physician but before theirtreatment is completed, and those who leave againstmedical advice. In studies from Los Angeles and SanFrancisco, CA, cohorts of patients who left EDs withoutbeing treated were followed up to document patientoutcomes.28-30 A small but troubling proportion of thesepatients (≤11%) were admitted to a hospital within 1week of the initial ED visit, and several required emer-gency surgery, indicating that leave-without-completing-treatment rates might be a useful marker of adverseoutcomes associated with ED crowding.

Another marker of EDs being unable to meet patientdemand is ambulance diversion. An ED that divertsambulances has signaled that it is no longer safely ableto care for another critically ill or injured patient. Therapid increase in ambulance diversion throughout thecountry is one of the most visible consequences of EDcrowding. These diversion statistics have led to manymedia reports and a new study of ED crowding by theGeneral Accounting Office.19,31,32 Although we did notbelieve that ambulance diversion was a comprehensivedefinition or measure of ED crowding, certainly it is animportant event to monitor. We included ambulancediversion and leave-without-completing-treatmentpatients in our conceptual model diagram as examples


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The final priority in the model-driven research andpolicy agenda is to develop and test interventions toalleviate ED crowding. The relative importance of oper-ational versus policy solutions is not yet clear; however,both types of interventions likely will be needed. In thesearch for operational solutions, a fundamental ques-tion emerges: Who is responsible for the efficiency ofcare delivery in the hospital? To find operational solu-tions for crowding, medical and administrative leadersmust accept greater responsibility for the efficiency ofcare delivery at their institutions. Hospital leadersshould routinely measure key throughput and turn-around times (with accountability for meeting institu-tional goals), improve the efficiency of ancillary andsupport services, and use information technology thatsupports care delivery.

Policy solutions for ED crowding are also needed, yetthey are more difficult to define and implement. Again,it is helpful to look at each component of the input-throughput-output model to identify how policies con-tribute to or alleviate ED crowding. Several changes inpayment policies might improve the efficiency ofpatient care, provide incentives for hospitals to moveadmitted patients out of the ED, and improve the abilityof providers to match the demand for emergency carewith appropriately staffed services. For example, Medi-care mandates a 3-day acute hospital stay before it willpay for skilled nursing facility care, which creates anincentive for inappropriate hospital admissions of EDpatients who could be cared for in a transitional careunit or skilled nursing facility. Reforms in paymentpolicies for clinical decision units and observation ser-vices may also be helpful.

Our conceptual model has important limitations.First, it was developed by a small group of investigatorsand does not represent the consensus of a large group ofexperts. However, the model has been presented andinformally discussed at several expert panel and re-search meetings and has been revised according to thesediscussions. The model also does not capture all of thepotential causes and consequences of ED crowding, nordoes it quantify the relative importance of the variouscontributing factors. But we do not believe that suffi-

of the consequences of ED crowding and to show howthe model illustrates normal patient flow and the bot-tlenecks that contribute to crowding. Although theseevents are linked to the throughput portion of Figure 2,the underlying causes of ambulance diversion andleave-without-completing-treatment patients may berelated to input, throughput, or output factors.

Although many potential causes of ED crowdinghave been identified, more research is needed to definetheir relative importance. Potential contributing fac-tors to ED crowding exist within each component of theinput-throughput-output conceptual model. The rela-tive importance of these contributing factors may varyacross hospitals and regions. By searching for causeswithin each component of the conceptual model, re-searchers are less likely to overlook important causes ofED crowding.

The development of measures and the identificationof causes of ED crowding will be the basis for the mostimportant priorities of a model-driven research andpolicy agenda. The first of these priorities is to betterunderstand the relationship between crowding and thequality of care. The Institute of Medicine has adopted 6goals for improving the quality of care that have becomethe focus of health systems across the country.33 TheInstitute of Medicine report states that care should besafe, effective, patient-centered, timely, efficient, andequitable. Although emergency patients and providerscan certainly provide anecdotes that describe how EDcrowding appears to have compromised quality in eachof these dimensions, there are no studies of how EDcrowding affects patient outcomes. We do not yet under-stand how ED crowding affects the outcomes that havethe greatest potential for motivating change: clinicaloutcomes, patient satisfaction, provider satisfaction,and the cost of care. Quality-of-care problems associ-ated with crowding also extend beyond the ED to in-clude patients who are diverted, those who leave with-out completing treatment, and those who avoid carealtogether because of prolonged waiting times. Rigorousstudy of the relationship between ED crowding and thequality of patient care must be a high priority for futureresearch.



Asplin et al

cient evidence exists to enable this type of classifica-tion, at least not beyond the opinions of providers. Wehave attempted to highlight the contributing factorsthat we believe are most important in our discussion ofthe model’s components.

The problem of ED crowding has, to various degrees,captured the attention and energy of emergencyproviders, hospital administrators, policymakers, andthe public across the United States. Now it is time tofocus our efforts on research, policy, and operationsmanagement agendas to alleviate the problem. Webelieve that the input-throughput-output conceptualmodel provides a practical framework for these agen-das. We hope the model will be useful for researchersand policymakers as they address the problem of EDcrowding and ultimately help guide them to the mosteffective solutions.

Received for publication November 14, 2002. Revision receivedApril 9, 2003. Accepted for publication April 17, 2003.

Supported by contract number 290-00-0015 from the Agency forHealthcare Research and Quality. The views in this paper are thoseof the authors. No official endorsement by the Agency forHealthcare Research and Quality or the Department of Health andHuman Services is intended or should be inferred.

Dr. Asplin’s work was supported by grant number K08-HS13007 fromthe Agency for Healthcare Research and Quality.

Reprints not available from the authors.

Address for correspondence: Brent R. Asplin, MD, MPH, Depart-ment of Emergency Medicine, Regions Hospital, 640 Jackson Street,St. Paul, MN 55101; E-mail [email protected].

R E F E R E N C E S1. Richardson LD, Asplin BR, Lowe RA. Emergency department crowding as a healthpolicy issue: past development, future directions. Ann Emerg Med. 2002;40:388-393.

2. Schull MJ, Slaughter PM, Redelmeier DA. Urban emergency department over-crowding: defining the problem and eliminating misconceptions. Can J Emerg Med.2002;4:76-83.

3. ACEP Crowding Resources Task Force. Responding to Emergency DepartmentCrowding: A Guidebook for Chapters. Dallas, TX: American College of EmergencyPhysicians; 2002. Available at: http://www.acep.org/library/pdf/edCrowdingReport.pdf.Accessed June 19, 2003.

4. Andersen AS, Laake P. A model for physician utilization within 2 weeks: analysis ofNorwegian data. Med Care. 1987;25:300-310.

5. Kellermann AL. Too sick to wait. JAMA. 1991;266:1123-1125.

6. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity ofCalifornia’s emergency departments, 1990-1999. Ann Emerg Med. 2002;39:389-396.

7. Kellermann AL. Deja vu. Ann Emerg Med. 2000;35:83-85.


8. Derlet R, Richards J, Kravitz R. Frequent overcrowding in US emergency depart-ments. Acad Emerg Med. 2001;8:151-155.

9. Kellermann AL. Access of Medicaid recipients to outpatient care. N Engl J Med.1994;330:1426-1430.

10. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primarycare. JAMA. 2003;289:1035-1040.

11. Murray M, Bodenheimer T, Rittenhouse D, et al. Improving timely access to pri-mary care: case studies of the advanced access model. JAMA. 2003;289:1042-1046.

12. Rask KJ, Williams MV, McNagny SE, et al. Ambulatory health care use by patientsin a public hospital emergency department. J Gen Intern Med. 1998;13:614-620.

13. Asplin BR. Tying a knot in the unraveling health care safety net. Acad Emerg Med.2001;8:1075-1079.

14. Jones DS, McNagny SE, Williams MV, et al. Lack of a regular source of careamong children using a public hospital emergency department. Pediatr Emerg Care.1999;15:13-16.

15. Rask KJ, Williams MV, Parker RM, et al. Obstacles predicting lack of a regularprovider and delays in seeking care for patients at an urban public hospital. JAMA.1994;271:1931-1933.

16. Adams JG, Biros MH. The endangered safety net: establishing a measure of con-trol. Acad Emerg Med. 2001;8:1013-1015.

17. American College of Emergency Physicians 1998-1999 Safety Net Task Force.Defending America’s Safety Net. Dallas, TX: American College of EmergencyPhysicians; 1999.

18. Institute of Medicine, Committee on the Consequences of Uninsurance. A SharedDestiny: Community Effects of Uninsurance. Washington, DC: The National AcademiesPress; 2003.

19. General Accounting Office. Hospital Emergency Departments: Crowded ConditionsVary Among Hospitals and Communities. Washington, DC: General Accounting Office;2003.

20. Wuerz RC, Milne LW, Eitel DR, et al. Reliability and validity of a new five-leveltriage instrument. Acad Emerg Med. 2000;7:236-242.

21. Hoffenberg S, Hill MB, Houry D. Does sharing process differences reduce patientlength of stay in the emergency department? Ann Emerg Med. 2001;38:533-540.

22. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowdingin United States teaching hospitals. Ann Emerg Med. 1991;20:980-986.

23. Gallagher EJ, Lynn SG. The etiology of medical gridlock: causes of emergencydepartment overcrowding in New York City. J Emerg Med. 1990;8:785-790.

24. Espinosa G, Miro O, Sanchez M, et al. Effects of external and internal factors onemergency department overcrowding. Ann Emerg Med. 2002;39:693-695.

25. Forster AJ, Stiell I, Wells G, et al. The effect of hospital occupancy on emergencydepartment length of stay and patient disposition. Acad Emerg Med. 2003;10:127-133.

26. Schull MJ, Lazier K, Vermeulen M, et al. Emergency department contributors toambulance diversion: a quantitative analysis. Ann Emerg Med. 2003;41:467-476.

27. Richards JR, Navarro ML, Derlet RW. Survey of directors of emergency depart-ments in California on overcrowding. West J Med. 2000;172:385-388.

28. Bindman AB, Grumbach K, Keane D, et al. Consequences of queuing for care at apublic hospital emergency department. JAMA. 1991;266:1091-1096.

29. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergencydepartment without being seen by a physician: causes and consequences. JAMA.1991;266:1085-1090.

30. Stock LM, Bradley GE, Lewis RJ, et al. Patients who leave emergency departmentswithout being seen by a physician: magnitude of the problem in Los Angeles County.Ann Emerg Med. 1994;23:294-298.

31. Goldberg C. Emergency crews worry as hospitals say, “no vacancy.” New YorkTimes. December 17, 2000;Section 1:39.

32. Silka PA, Geiderman JM, Kim JY. Diversion of ALS ambulances: characteristics,causes, and effects in a large urban system. Prehosp Emerg Care. 2001;5:23-28.

33. Committee on Quality of Healthcare in America. Crossing the Quality Chasm:A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001.

Introducción

La saturación de los servicios de urgencias esun grave problema que afecta a países tan diver-sos como Estados Unidos1, Inglaterra, Australia, Es-paña, Canadá, Nueva Zelanda o Taiwán2. Los fac-tores que intervienen en este problema sonmuchos, pero podemos agruparlos en tres tipos:los que tienen que ver con la demanda o factores“de entrada” (visitas no urgentes, pacientes poli-frecuentadores, aumento de frecuentación durantelas crisis hivernales), los que tienen que ver con laeficiencia o la capacidad de respuesta del propio

servicio de urgencias hospitalario (SUH) (dimensio-namiento de la plantilla, profesionalización y capa-cidad de resolución de la plantilla del SUH, déficitestructurales, demoras de las exploraciones diag-nósticas), y los factores relacionados con el drenajedel servicio o factores “de salida” (adecuación deingreso, insuficientes camas de hospitalización,competencia con el ingreso programado)3,4.

La permanencia excesiva en espacios propiosdel SUH de pacientes que ya han sido ingresadosen servicios de hospitalización es una de las prin-cipales causas evitables de saturación de los SUH5.Las soluciones a este problema difícilmente pue-

Emergencias 2010; 22: 249-253 249

ORIGINAL

Impacto de la implementación de medidas de gestiónhospitalaria para aumentar la eficiencia en la gestión decamas y disminuir la saturación del servicio de urgencias

ANTONI JUAN1, EVA ENJAMIO1, CARLES MOYA1, CRISTINA GARCÍA FORTEA1, JUAN CASTELLANOS3,JOAN RAMÓN PÉREZ MAS3, JAVIER MARTÍNEZ MILÁN3, LUIS LORES3, JOAN URGELLÉS3,BERNABÉ ROBLES3, ESTER BOU3, CÉSAR ROMERO3, JOSEP MÉNDEZ3, JOSÉ SAAVEDRA3,MANUEL CÉSPEDES3, MARTA MORERA3, RAFAEL VERA3, CONCEPCIÓN FÉRRIZ3, SARA TOR2, ROSA RAMÓN1

1Dirección y Gestión de pacientes. 2Dirección de Enfermería. 3Jefes de Servicios Médicos y Quirúrgicos.Hospital General del Parc Sanitari de Sant Boi de la Orden Hospitalaria de Sant Joan de Déu. Sant Boi deLlobregat. Barcelona, España.

Objetivo: Analizar el impacto de la implementación de medidas para reducir el númerode pacientes ubicados en urgencias en espera de cama de hospitalización.Método: Tipo de estudio: comparativo con un análisis retrospectivo. Se compararondos periodos: periodo 1 (nov 06-oct 07) y periodo 2 (nov 07-oct 08). Ámbito: Hospitalde Sant Boi, hospital general de 126 camas, en Sant Boi de Llobregat (Barcelona). Me-didas implementadas: disminución de la estancia prequirúrgica, incremento de la ciru-gía mayor ambulatoria (CMA) y potenciación del ingreso en una unidad de corta es-tancia médica (UCE). Variables estudiadas: admisiones en el SUH, ingresos hospitalarios,ingresos de CMA, el número de días en que hay al menos 1 paciente pendiente de ca-ma hospitalaria en el SUH a las 8:00 horas, estancia promedio hospitalaria, actividad yestancia promedio en la UCE.Resultados: El total de admisiones en el SUH fue de 57.140 en el periodo 1, y 71.280en el periodo 2, con 4.840 (8,4%) y 5.385 (7,5%) ingresos, respectivamente. La estan-cia media de hospitalización disminuyó de 5,2 días a 4,5 días (p < 0,001). En 86 díasdel periodo 1, uno o más pacientes permanecían en el SUH pendientes de cama (307pacientes/año), frente a 11 días en el período 2 (26 pacientes/año).Conclusiones: En nuestra experiencia, las medidas de gestión aplicadas fueron eficacesen la disminución del número de pacientes pendientes de cama en urgencias. [Emer-gencias 2010;22:249-253]

Palabras clave: Saturación. Servicio de urgencias. Gestión de pacientes. Unidad decorta estancia.

CORRESPONDENCIA:Dr. Antoni Juan PastorDirección MédicaParc Sanitari de Sant BoiC/ Buenaventura Calopa, 1308830 Sant Boi de LlobregatBarcelona, EspañaE-mail: antoni.juan @ pssjd.org

FECHA DE RECEPCIÓN:27-1-2010

FECHA DE ACEPTACIÓN:6-4-2010

CONFLICTO DE INTERESES:Ninguno

AGRADECIMIENTOS:A todo el personal asistencial ydel servicio de admisiones, enquien recae la responsabilidadde coordinar la gestión decamas del hospital.

249-253-C01-12514.EME-ORIGINAL-Juan:C10-12346.EME ORIGINAL-Fernandez 19/07/10 11:08 Página 249

den ser adoptadas desde el propio SUH. La res-ponsabilidad de una adecuada gestión de pacien-tes que incluya una correcta gestión de las camashospitalarias es una responsabilidad de la direc-ción de cada centro hospitalario a través de sudepartamento de gestión de pacientes6.

Las dos vías de acceso a una cama hospitalariason la admisión programada o la admisión urgen-te. La admisión urgente proviene en su prácticatotalidad del SUH y en un alto porcentaje se debea patología médica. En cambio la mayoría de pa-cientes que ingresan programados son tributariosde realizar algún procedimiento quirúrgico, y esexcepcional el ingreso programado por causa depatología médica. La gestión adecuada de camashospitalarias debería garantizar todos los días delaño un número suficiente de camas para la admi-sión urgente sin necesidad de suspender las admi-siones programadas. En lo que hace referencia alingreso por patología médica, en los últimos añoshay suficientes experiencias publicadas sobre laeficacia de las unidades de corta estancia (UCE)que permiten disminuir las estancias promedio de hospitalización en patología médicas prevalentes7-11.Del mismo modo, la ambulatorización de los pro-cesos quirúrgicos mediante la cirugía mayor am-bulatoria (CMA) contribuye a una mejor gestiónde las camas hospitalarias12,13.

El objetivo de este artículo es presentar los re-sultados obtenidos tras aplicar medidas para me-jorar la eficiencia en la gestión de camas hospita-larias.

Método

El estudio se realizó en el Hospital General deSant Boi del Parc Sanitari de Sant Boi de Llobregat,de la Orden Hospitalaria de San Juan de Dios. Setrata de un hospital general de ámbito comarcal de126 camas situado en el área metropolitana de Bar-celona, con una población de referencia de 120.000habitantes, y que pertenece a la red pública de hos-pitales de Cataluña. Cuenta con las especialidadesmédicas y quirúrgicas propias de su nivel y una uni-dad de semicríticos. En el SUH se atienden urgen-cias generales de pacientes adultos, y, desde no-viembre de 2007, también urgencias pediátricas.

Es un estudio comparativo con análisis retros-pectivo de dos años de actividad: el periodo denoviembre 06-octubre 07 (periodo 1) y el periodode noviembre 07-octubre 08 (periodo 2). Entreestos periodos se produjo un cambio en la estra-tegia para la gestión de camas del hospital y seimplementaron una serie de medidas, el impacto

de las cuales son objeto del presente estudio: lareducción de la estancia pre-quirúrgica, y el incre-mento de la CMA y la actividad de una UCE co-mo una alternativa a la hospitalización convencio-nal para las patologías médicas.

Las variables estudiadas fueron el número totalde admisiones en el SUH, de ingresos hospitala-rios procedentes del SUH, de ingresos programa-dos, de ingresos de CMA, de días que uno o máspacientes están a las 8:00 en el SUH pendientesde cama de hospitalización, estancia promedio dehospitalización, peso promedio de los grupos rela-cionados de diagnóstico (GRD) de pacientes in-gresados, de ingresos en UCE y la estancia prome-dio de UCE. Directamente relacionados con laseguridad, se analizan los reingresos los 30 díasposteriores al alta, la tasa de complicaciones qui-rúrgicas y la tasa de mortalidad. Los datos fueronobtenidos del sistema de información de admisio-nes y del conjunto mínimo básico de datos(CMBD). El análisis de las complicaciones se reali-zó con el programa CLINOS® directamente desdeel CMBD. Hemos considerado como indicador dela adecuación de la gestión de camas el númerode días que uno o más pacientes están ingresadospendientes de cama en el SUH14.

El análisis descriptivo de los datos aparece comomedia (intervalo de confianza del 95%) o como unnúmero absoluto de casos y porcentajes. Para el es-tudio de las diferencias entre grupos de pacientes,se utilizó la prueba de análisis de la varianza en elcaso de las variables cuantitativas paramétricas y laprueba de Mann-Whitney en el caso de las no pa-ramétricas. El límite de la significación estadística sedetermina en un error de 0,05.

Resultados

En la Tabla 1 se muestra el resumen de los da-tos generales. El aumento en el segundo periododel número total de admisiones del SUH se debea la apertura del área de urgencias pediátricas ennoviembre de 2007. Ésta es la razón de la dismi-nución en el porcentaje de ingresos urgentes. Encontraste, el número absoluto de ingresos desdeel SUH aumentó (Tabla 1, Figura 1). Consideradossólo los pacientes adultos, el porcentaje de ingre-sos urgentes aumentó en el periodo 2. En cambioel número de días en que uno o más pacientesestán esperando cama en el SUH a las 8:00 dismi-nuyó, como se muestra en la Figura 2.

En la Tabla 2 podemos ver los datos de la acti-vidad hospitalaria en general. La disminución delpromedio de estancia en los servicios médicos y

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en los servicios quirúrgicos es muy notable consignificación estadística (de 5,2 a 4,5 días). Porotro lado se produce un gran aumento del núme-ro de pacientes ingresados en UCE. Un dato rele-vante es que en el periodo 2 aumentaron los in-gresos programados. La mortalidad y las tasas decomplicaciones han mejorado durante el periodo2, aunque sí se ha detectado un incremento delos reingresos durante los primeros 30 días poste-riores al alta.

Discusión

En nuestra experiencia, las medidas adoptadaspara reducir la estancia media de hospitalizacióncon la consiguiente disminución de la ocupaciónhan sido eficaces en la reducción de los pacientesingresados pendientes de cama en el SUH.

Podríamos enumerar tres puntos claves paraadoptar las medidas más apropiadas. En primerlugar, el análisis de la situación para detectar losposibles focos de ineficiencia. En nuestro caso, eramejorable la estancia pre-quirúrgica, el porcentajede cirugía ambulatoria y la estancia promedio deservicios médicos. En segundo lugar, la comunica-ción de las medidas a adoptar a todos los servi-cios implicados. Y finalmente, la adopción de unmodelo centralizado de gestión de camas. El ser-vicio de admisiones es el responsable de centrali-zar la información necesaria para la gestión diariade camas. La información básica para conocer aprimera hora de la mañana cuál va a ser la previ-

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Tabla 1. Resumen de los datos generales del estudio

Periodo 1 Periodo 2

Total admisiones SUH 57.140 71.280Total admisiones SUH adultos 57.410 55.181Total ingresos procedentes del SUH 4.834 5.385% ingresos urgentes (respecto nº urgencias) 8,4 7,5% ingresos urgentes (respecto nº urgencias adultos) 8,4 9,75Total ingresos programados 3.607 3.847Ingresos CMA 1.367 1.894% CMA/ingresos programados 37,89 49,23Total días/año con 1 o más pacientes pendientes

de cama en el SUH a las 8:00 86 11Total pacientes pendientes de cama

en el SUH a las 8:00 307 26% pacientes pendientes de cama/nº total de ingresos procedentes del SUH 6,3 0,5

SUH: Servicio de urgencias Hospitalario. CMA: Cirugía mayorambulatoria.

Figura 1. Número comparativo de ingresos procedentes deldervicio de urgencias hospitalario (SUH) en ambos periodos.

Tabla 2. Resumen actividad de hospitalización. Actividad de hospitalización

Periodo 1 Periodo 2 P

Estancia promedio de hospitalización* [en días, media (IC 95%)] 5,2 (5,0-5,3) 4,5 (4,4-4,7) < 0,001Peso promedio GRD [media (IC 95%)] 1,3 (1,0-1,5) 1,3 (1,0-1,4) nsPromedio índice de Charlson [media (IC 95%)] 0,7 (0,6-0,8) 0,7 (0,6-0,8) nsEstancia promedio servicios médicos [en días, media (IC 95%)] 7,1 (6,9-7,4) 5,9 (5,7-6,1) < 0,001Estancia promedio servicios quirúrgicos [en días, media (IC 95%)] 3,9 (3,8-4,1) 3,5 (3,3-3,7) < 0,001Nº ingresos UCE 188 1.137Estancia promedio UCE [en días, media (IC 95%)] 3,2 (2,9-3,4) 4,1 (3,9-4,2) < 0,001Peso promedio GRD UCE [media (IC 95%)] 0,8 (0,7-0,9) 1,3 (1,1-1,4) < 0,01Ratio de complicaciones total (%) 1,2 1,2 nsRatio de complicaciones quirúrgicas (%) 3,3 2,4 < 0,01Reingresos a los 30 días post-alta (%) 3,6 4,5 0,001Ratio de mortalidad (%) 3,1 2,7 ns*Exluidos pacientes de CMA. GRD: Grupos relacionados de diagnóstico. UCE: Unidad de corta estancia. ns: no significativa.

Figura 2. Número de pacientes pendientes de cama a las 8:00horas. Arriba: periodo 1. Abajo: periodo 2.


sión del día es: número de camas activas, pre-avi-sos de alta, número de pacientes programadospara cirugía con necesidad de cama hospitalaria yprevisión de ingresos urgentes. En caso de que laprevisión de camas para el ingreso urgente esti-mado de ese día sea inferior a la necesaria, se to-marán las medidas oportunas: comunicar a losrespectivos servicios la necesidad de no diferir al-tas, revisar aislamientos, etc.

En cuanto a los resultados obtenidos en nues-tra experiencia, aunque la estancia media globalse ha reducido significativamente, llama la aten-ción el aumento de la estancia media de los pa-cientes ingresados en UCE. Esto se debe a unamayor selección de los pacientes en el periodo 1y que se refleja en un menor peso promedio deGRD del periodo 1. Sin embargo, hemos conse-guido el objetivo inicial de garantizar una estanciamedia no superior a 4 días.

Simultáneamente a la disminución de la estan-cia promedio global, la tasa de mortalidad ha dis-minuido y las complicaciones quirúrgicas se hanreducido. En cambio, como dato negativo, la re-admisión en los 30 días después del alta se ha in-crementado. En el caso de las patologías crónicas,como la enfermedad pulmonar obstructiva cróni-ca, es común analizar los reingresos a 60 días15, oa 3 meses16 después del alta. No obstante, el rein-greso a 30 días es un indicador que nos es útilpara monitorizar la seguridad del alta, de modoque nos puede orientar hacia la necesidad deadoptar algunas medidas complementarias (mejo-ra control al alta, garantizar la continuidad asis-tencial con atención primaria, etc.).

La saturación de los SUH y sus consecuenciasson una responsabilidad directa de las direccionesasistenciales del hospital17. Las consecuencias de lasaturación de los SUH están descritas en la litera-tura médica. Entre ellas podríamos enumerar: dis-minución de la seguridad de los pacientes atendi-dos en urgencias, el aumento de la duración deldolor y del sufrimiento de los pacientes, con lar-gas esperas e insatisfacción de los pacientes, burn-out del personal de los SUH con una disminuciónde la eficacia clínica, violencia contra los profesio-nales, efecto negativo sobre la docencia y la in-vestigación en los SUH, consecuencias médico-le-gales, etc.18-21. Vistas las consecuencias, no seríaético por parte de las direcciones de los hospitalesno tomar medidas para evitar la saturación de losSUH22. Asplin et al., se preguntan: "¿Quién es elresponsable de garantizar la eficiencia de la pres-tación de atención en el hospital?". En su artículoconsideran que son los dirigentes de los hospitaleslos que deben tomar las medidas y encontrar so-

luciones4. Desde nuestro punto de vista, es la di-rección del hospital quien debe planificar y coor-dinar las medidas oportunas, con la estrecha cola-boración de todos los jefes de servicio que, atodos los efectos, tienen responsabilidades sobrela gestión de pacientes y sobre el uso eficiente delas camas hospitalarias.

Además de una planificación adecuada del to-tal de ingresos programados a lo largo de todo elaño, la gestión diaria de camas es clave. Vermeu-len et al.23 proponen la ratio ingreso/alta diario co-mo un concepto atractivo para que los gestoresdel hospital lo tengan en cuenta en su planifica-ción. En su artículo concluye que el desequilibrioentre el número de ingresos y altas en el mismodía afecta significativamente al día siguiente en laestancia promedio de los pacientes en el SUH. Ennuestro caso, esta ratio estimada de ingresos/altases controlada en la reunión diaria de gestión decamas y es nuestro principal indicador para lagestión del día a día.

Un aspecto esencial de la gestión adecuada decamas es evitar la suspensión de la programaciónquirúrgica, puesto que tiene consecuencias nega-tivas para el paciente, la organización y la finan-ciación del hospital24. Moskop et al., se refieren ala priorización de los ingresos programados comouno de los obstáculos para resolver el problemade la disponibilidad de camas para ingreso urgen-te. En cambio, nuestra experiencia muestra quemientras se adoptaban medidas que tenían comoobjetivo paliar la saturación del SUH, simultánea-mente aumentaron los ingresos programados.

Aunque pensamos que nuestro método de tra-bajo es exportable a cualquier centro hospitalario,se podría interpretar como limitación de nuestroestudio el hecho que hace referencia a la expe-riencia de un único centro hospitalario. Sería ne-cesario realizar un plan de actuación similar enotros hospitales para corroborar su eficacia.

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Impact of hospital management measures on improving the efficiency of bed allocationand reducing emergency department overcrowding

Juan A, Enjamio E, Moya C, García Fortea C, Castellanos J, Pérez Mas JR, Martínez Milán J, Lores L, Urgellés J,Robles B, Bou E, Romero C, Méndez J, Saavedra J, Céspedes M, Morera M, Vera R, Férriz C, Tor S, Ramón R

Objective: To analyze the impact of hospital management measures to reduce the number of patients held in anemergency department while awaiting admission.Methods: Type of study: retrospective, comparing 2 periods, November 2006 to October 2007 and November 2007 toOctober 2008. Setting: Hospital de Sant Boi, a 126-bed general hospital in Sant Boi de Llobregat in the province ofBarcelona. Management measures: decreased presurgical stay, increased use of ambulatory surgical procedures, andincreased use of a medical short-stay unit. Variables studied: emergency department admissions, hospital wardadmissions, admissions for ambulatory surgical procedures, number of days in which at least 1 patient was in theemergency department at 8 A.M. while waiting for a bed, mean hospital stay, and admissions and average time spent inthe short-stay unit.Results: A total of 57140 patients were admitted to the emergency department in the first period and 71280 in thesecond period; 4840 (8.4%) were admitted to hospital in the first period and 5385 (7.5%) in the second. The averagelength of stay was 5.19 days in the first period and 4.54 days in the second (P<.001). At least 1 patient was waiting inthe emergency department for a hospital bed to become available on 86 days in the first period (307 patients/year) and11 days in the second period (26 patients/year).Conclusions: The management measures applied in this case were effective in reducing the number of patients held inthe emergency department while waiting for admission. [Emergencias 2010;22:249-253]

Key words: Emergency department overcrowding. Patient flow management. Short-stay unit.


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